MEDICARE: MRS. JOEY LYN SJOSTROM RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	844423	CA
2	133V00000X	Registered Dietitian	38696DI-0	NV

General Provider Information

NPI Number	:	1396889507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOEY LYN SJOSTROM RD

Provider Business Mailing Address
First Line	:	10961 SHALLOW WATER CT
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-8721
Country	:	US
Telephone Number	:	702-878-5639
Fax Number	:	480-247-4491

Provider Business Practice Location Address
First Line	:	8275 S EASTERN AVE
Second Line	:	SUITE #118
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-2591
Country	:	US
Telephone Number	:	702-878-5639
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	10/06/2015

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